Loading...
HomeMy WebLinkAboutMiscellaneous - Exception (87)75.E Date .�!Z//> . X l/ ...... TOWN OF NORTWANDOVER PERMIT FOR NSTALLATION ti This certifies that ...CSL?.� has permission for gas installation ..... .................. in the buildings of ... �� !. �, it .( ............................. . at ... C/'. .................. North Andover, Mass. Fee. ' Lic. No.... GAS INSPECTOR Check # .4 w MASSACHUSETTS UNIFORM APPLICATION FORE TO DO GASFITTING -AUpp Mass. Date l l 20 /© Permit # Building Location Owner s Name l� t tTL `p QAui S I Type of Occupancy New n Renovation rigalacement El Plans Submitted: Yes ❑ No 8-- G Installing Address Business Telephone Name of Licensed Plumber or Gasfitter C Check one: Er-C-orporation Partnership ❑ Firm/Co. Certificate JJ6 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes ET— No ❑ If you have checked yes, please indicate thetype of coverage by checking the appropriate box_ A liability insurance policy 0---- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MGL, and that my, signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions jfssAState Gas Code and Chapter 142 of the General Laws. By Type of License: Title .Er -Number Master Si a o Licensed Plumber/Gasfitter City/Town ❑ Gasfitter ❑ Journeyman License umber / APPROVED OFFICE USE ONLY • ; ME ME ME MENEM ME ME MEN Business Telephone Name of Licensed Plumber or Gasfitter C Check one: Er-C-orporation Partnership ❑ Firm/Co. Certificate JJ6 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes ET— No ❑ If you have checked yes, please indicate thetype of coverage by checking the appropriate box_ A liability insurance policy 0---- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MGL, and that my, signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions jfssAState Gas Code and Chapter 142 of the General Laws. By Type of License: Title .Er -Number Master Si a o Licensed Plumber/Gasfitter City/Town ❑ Gasfitter ❑ Journeyman License umber / APPROVED OFFICE USE ONLY rl 9862 12-- 13- /0 Date........................... TOWN OF NORTH ANDOVER va PERMIT FOR WIRING This certifies that ................... b ( -� ......... �� .............. has permission to perform ........ ae:4A K4 .................................. wiring in the building of ........... Orr�/� ................................................ ..... IA?�.-6405P / at .... .. ........ NortthhAndover, Mass. Fee ..-;?fIP--.... Lic. No. ..........:1` ....... . .. Check # r r ' � �ttia 0� %laldach�daRO .UePar%t o��lre �irvkee BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 4f. Z, -- Occupancy Occupancy and Fee Checked Rev. 1/07) leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to bo porformod In acoordmoo with the Ma3mchu3cm Elootr W Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL 1NFORMAT1ON) Date: 12 '/q 1O City or Town of: lVoa,,r To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below Location (Street & Number) Owner or Tenant t�i-Z- avis 57— Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overbead ❑ Uadgrd ❑ New Service Amps / Volts Overbead ❑ Undgrd ❑ No, of Meters No. of Meters Number of Feeders and Ampaelty Location and Nature of Proposed Electrical Work; �at,eF &4S Bored Completion of0wMlowing table may be waived by the Inspector of Wires No. of Recessed Lumlaalres No. ofCoIL Susp. (Paddle) Fans Trransrormers KV^ No. of Luminalre 0ytlet3 No. of Hot Tubs Generators KVA 1 No. of Luminaires Above n- Swimming Pool rad. C]jZ In- ❑ o, o mergency Lighting Batte Units No. of Receptacle Outlets No. of OU Burners FIRE ALARMS No. of Zones No. orswitches N0. Of Cas Burners %' o. o e oct ou an InItladne Devices No. of Ranges Total No. of Alr Coad. Tons No, of Alerting Devices No. of Waste Disposers P� Heat ump T tabs Number "�""— ons,,,„ -,--_ - - o. o e - onta ne Vellection./Alerilag Devices No, of Disbwasbers Space/Arts Heating KW Local ❑ CYYonne icipeon C1 Other No. of Dryers Heating Appllances , KW �No. of Devi10 ctes or Equivalent No. of WaterNo. Heaters KW o signs Balla3t3 Data Whi N0. ne: of Devices or Equivalent No. H dromassa a Batbtubs y e No. of Motors Total HP a No or De canons :terse: N0. of Devices or E uivalent OTHER: Attach addlllonal dttall Udttired or ar required by the /nsptctor o/wirer Estimated Value of Electrical Work: (When.roquirod by municipal policy.) Work to Stan: Inspoetions tq be roquestod in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE; Unless walvod by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability Wunwwo including "completed operation" coverage or its substantial equivalent. The undersigned oerdAcs that such oovwgo Is In tome, twd has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE a BOND ❑ ,OTHER ❑ (Spoclfy:) / certify, under the palnd and penakla Vptrjury, Kral the Infornw4on on this appUeatlon Is true and eorrtplere. FIRM NAME: T R I II -t(; L LIC. NO.: I `� (v 3q Licensee: DAPI► 0 HA(q4AoZ Signature �- LIC. NO.: '•_ (If applicable, enter "exempt" In the lkvmt numbs1 Bus. Tel. No. `118 ' b8Z'��� L Address: 91 Art -mow Sr. N TH Ati20\4P, � D 1 H AIL Tet. No•:3 1 f -37 5. 5-7 3 -1 Per M.G.L, c. 147, s, 57-6 1. security work requires Depvtment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am switn1bal the Licensee dots not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) (I owner owner's a cnt. Owner/Agent Signature Tolepboae No. PERMIT FEE: 5 r ti The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): PA\4(O L' LC C 1_ iZ (CAL CG N i9Ac T I N G L L.C. Address: 9-7 6ELri0;-J-r Sr City/State/Zip: NOR M I l00V'50, ire.. 016q5' Phone #: `1� 8 02 Z � Are you an employer? Check the appropriate box: 1. [9 1 am a employer with 8 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp• insurance? required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required] t c. 152, §1(4), and we have no employees. [No workers' msurance Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *My applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information, n Insurance Company Name: 4M oy P, Amegi cAi4 Policy # or Self -ins. Lic. #: w 2 i J 5o 9 O 1 7 Z Expiration Date: 3— l"[ Job Site Address: &2 ST City/State/Zip: /ter 4aD&,,LzO/M-_ y Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a i fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coverage verification 1 do hereby certify under th1t'pain n ,enalties of perjury that the information provided above is true and correct. I-- nat, 12-AVII., /`., Phone #: 7 B " 1� e,2 —192 �,.2 use only. Do not write in this area, to City or Town: or town of kiaL Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Il Contact Person: Phone #: fiAl -, (, � -014 / Z - / 7 - I �/- �, 0